Hormone Replacement Therapy Myths and Truths With Dr. Anna Garrett

Introduction and guest background 0:00

Hello, and welcome to the Thyroid Pharmacists Healing Conversations podcast. I'm your host, Dr. Isabella Wentz, your thyroid pharmacist. And today, I am really excited to get into some of the myths of hormone replacement therapy with my fellow pharmacists, Doctor Anna Garrett. Doctor, Anna, welcome. It's so great to have you here. Oh, my gosh, it's my pleasure. It's always wonderful to have another pharmacist because I know we like to really nerd out and get into like the various treatment options.

And so super excited for the opportunity to pick your brain today. So you have been on a career path for over 30 years and have worked in a variety of different practice settings. And right now, what you found is women in midlife is your true passion. So you have a functional medicine approach, which includes hormone balancing, weight loss, gut health, personalized wellness plans, and health coaching. All of your programs are designed to help women and mid-life stay their healthiest and feel amazing in their bodies so they can keep rocking their mojo through menopause and beyond.

I'm really excited because you actually have a book called Perimenopause, The Savvy Sister's Guide to Hormone Harmony, and this is something that you published back in 2019 when nobody else was really talking about poor menopausal. And so I really appreciate you being ahead of the curve. I know I didn't fully appreciate perimenopause until it hit me like a ton of bricks in 2020, and I was actually in my 30s when perimentopaus hits. I'm not sure what your experience has been, but I am hearing that lately it's been happening a little bit earlier in women potentially maybe stress or that the pandemic sort of accelerated at all.

Well, and exposure to toxins and, you know, um, Xenoestrogens. So, I mean, it's sort of multifactorial, but yes, the clients I'm seeing, when I do their testing, they can be in like their early to mid thirties now. And it like, wait a minute. I think a lot of it is stress. Yeah, I didn't realize that I thought I would be like maybe 48 or 49 when that happened. And it was like, what what is going on here? It can definitely be super confusing. Super annoying. All of the things that you thought worked well for your body all of a sudden don't work anymore.

Um, and yeah, i'm curious what brought you into the world of perimenopause? Was it your own Journey or was it seeing some of your patients and clients. Well, so as I've created this business, I have been my ideal client sort of at every stage that I focused on. I really focused perimenopause, truthfully, because there was so little information out there. So when I wrote the book, it really was sort be designed to be the what to expect when you're expecting perimenopause version so because you know my clients were like nobody ever told me anything and I like we didn't know so I I used to do health coaching at the hospital I worked at before I started my business and um I would get women coming in they'd be 49 about to turn 50 and they just be reeling off this whole list of things that was happening.

And then personally, I wasn't sleeping. I was having these crime scene periods. So I hadn't gone down the deep dive of the rabbit hole of hormones at that point. And so I was like, well, you know, as a pharmacist, I've got all this training and something is definitely going on and I feel like I can make a difference. And, so, the other reason I focused on perimenopause was because, As a Pharmacist I couldn't write prescriptions without having... I could do that with a supervising physician in this state, but I wanted to operate a little more broadly.

And lifestyle is such a key foundational part of managing perimenopause that with. Lifestyle and supplements, I knew that I could make a huge impact for a lot of women. So that's why I chose to go specifically down that path.

Perimenopause timing and early symptoms 4:38

Now I do more menopausal moving in more in a direction of. Longevity overall now because now I'm sixty six when I started my business. I was fifty. So, you know, got to keep moving with the times. Mostly to help my health and then translate that into how to how, to, help other women as well. I love that you stay curious and that You keep learning is so incredibly important. I think if you're wanting to have a healthy brain and having that vibrancy in life, and I appreciate you because I get to learn from you and take a little bit of a shortcut.

A lot of the people listening whether they're in their childbearing years, whether they're in perimenopause or they are in menopausal already, there's a lot to learn, right? There's lot learn about hormones and unfortunately, I feel like when I was going through pharmacy school, the hormones were sort of vilified. We went from filling all these prescriptions for hormone replacement therapy to all of a sudden, this is going to cause cancer. Can we talk a little bit more about that myth or some of the misconceptions?

Sure. You know it's interesting that that we're starting with this because it was definitely the first thing on my list and I assume that everybody already knows that hormones don't cause cancer but clearly they don' because I see it at least 10 or 20 times a week. Some women all respond to a social media post and Say, oh, I can't take, you know, hormones are going to cause cancer. They're dangerous. Blah, blah, and not 2 days ago, some somebody else has published a slice and dice of the women's health initiative again.

And the title was, Oh, no hormones after age 65 increases cardiovascular risk greatly and I was like. We were still going to do this. So, the 1st thing I would say is estrogen does not cause cancer. There have not been any studies that show that estrogen causes cancer and. The, the bad actor in the women's health initiative turned out to be the synthetic progestin. In addition, they used primary and are conjugated equine estrogens, which is not a product that is commonly used anymore at all. And.

you know, neither are synthetic progestins unless we're talking about birth control pills or IUDs. Generally, we are using bioidentical pro testosterone at this point. So there's just no data. And so for your listeners who really want to get informed about estrogen and its benefits and what the studies actually say, I highly recommend the book Estrogen Matters, But from blooming and Carol Tavris, he is an oncologist. She is a. PhD. social scientist, I think I can't remember exactly what our training is.

But it's a little bit of a dense book if you don't have a scientific background, but it will definitely go into all the details. And, you know, it is a book I actually took to my doctor because I wanted to go on estrogen and I have a terrible family history of breast cancer. In fact, I think my daughter and I and one aunt are the only ones that haven't had it. My mom died of it, my sister had at 40, and, you know, i'm like, And so I took her the book. She did actually read it. And she's like, OK, I will prescribe this for you.

I don't really want to do it, but I'll do because I know you know what you're talking about. So that was three years ago. Estrogen just changed my life. And I go and I, you know, I get a regular mammogram, what is it I've been having lately, a breast MRI, just to make sure that everything is cool. And if that's what it takes for her to be willing to prescribe that for me, i'm all about it. So, and i want to stay stay safe, even though I know. That estrogen does not cause breast cancer. So I feel like the pendulum is swinging.

And some days it feels like this, the pendulum is swimming maybe a little too much because now. the message that influencers are putting out there is that everybody should be on hormones. And I don't know that we actually know, that's true. But I'm glad to see that physicians are, if they have any background in hormones, are much more willing to prescribe for a much broader range of patients, but I swear there are still I don't even know how many physicians out there are still operating on 2002 data and just saying they don' believe in hormone therapy.

And then, you know, there's still women that are just left to suffer for no good reason. Yeah, it's really interesting. I read somewhere that the practice of medicine is behind by 10, 20, sometimes 30 years, but there's the published research, what people are seeing, clinical research and then the average primary care doctor or even a gynecologist might be many years behind of what the new research has shown. I want to ask you a little bit more about your healing journey and then just we're going to go through some of the myths, but before we do that, Can we back up a little bit and talk about the basics?

Hormone therapy basics and terminology 10:40

What exactly is hormone therapy? How does it differ from what most people think? Which hormones are we talking about? So what I'm talking specifically about right now, and we can get into other things if we have time, is estradiol, micronized progesterone or the oral form and testosterone. And so that now instead of being called hormone replacement therapy is now more popularly but I don't know if it's more popularity but it is more correct to cause it to call it menopausal hormone therapy. So there are a lot of terms that get put out there so there's HRT, there's MHT.

There's bioidentical hormone therapy. there is body identical hormone. And for the most part, and then there are compounded hormone therapies, which is in my mind, a subsection of bio identical hormones. We can talk about compounding too, because I have some fairly strong opinions about that. So they all essentially mean the same thing. So when I say hormone therapy, I'm talking about estradiol and progesterone and testosterone. We do still have the synthetic projestins that are used in birth control pills, along with synthetic estrogens.

Testosterone does not have an FDA approved product available for women. And I have some strong opinions about that too. So we have to either get it compounded. which can be in the form of a cream, it can fit be, in, the, form, of an oral trochee, which is a little tablet you put under your tongue and let it dissolve, or we can, um, be expected to squeeze a one-tenth dose of, a, male, uh, testosterone gel and apply that. So I don't know how accurate that is. I mean, is it pea-sized? What does a pea look like?

You know, what are we doing here? So we're asking women to make do with something that they should have their own product for. So those are the terms. Body identical and bio identical to me are same thing. So what that means is a hormone replacement product that is chemically identical what your body would normally produce if it were still optimally producing hormones. The synthetics have got a chemical modification that allows a drug company to patent them and then sell them for big bucks. And that's really how Madroxyprogesterone came about.

You'll hear people say that, you know, it was to avoid side effects and it's because progesterin wasn't well absorbed, but it really was about the money. I know that sounds very cynical, but a lot of what goes on in the drug industry is really about the money and how marketable a product is to make profits for the company. Yeah, I mean, i had worked in pharmaceutical sales for a short time and I had an amazing salary. I have a company car. A huge marketing budget where I was able to spend I want to say a hundred dollars a person on fancy dinners in Chicago and there was a 100 of me like just I'm assuming for specific portfolio of medications calling on pharmacists where there is hundreds of others reps for that company calling on doctors, nurse practitioners, focusing on different drugs.

It takes a lot of money to bring a drug on the market and it has to be Patentable I think when I was going through pharmacy school is like a billion dollars or something. I'm sure I am sure it's even more now and then you have all of your marketing money that you spend your FDA money and so it has to be something that the pharmaceutical companies can make a return on their investment. And so a lot of times what ends up happening is we don't hear about these bio identical hormones or natural treatments or supplements because nobody can really patent them.

The only patent is like a delivery system. So I know. like fish lavasa or fish oil. They were able to patent that because of the way that it was delivered. And then they were to show that something that a lot of integrative practitioners have known that fish, oil has health benefits. Of course, their product was very, very expensive. It was a great product, but at the same time, it really is that reality that is in the world where progesterone might be a perfectly safe and acceptable compound, but because it is the same from what we think, we're not going to be able to benefit from all of the marketing and all the awareness campaigns created by pharmaceutical companies.

And so that's why podcasts and bloggers and the healthcare influencers and these conversations need to happen because a lot of times people just are not aware. They just think that you know, hormone therapy is dangerous, right? Maybe that message got out there with that one study. Perhaps this was something that was passed down from, you, know pharmaceutical marketing reps. I'm not sure if that is the message they were given to go with, but I think a lot of times people do end up having this fear.

So I am really grateful that you've dispelled it. Going back to talked about like the different ages where women can have some onset of symptoms. I've heard different things where they'll say like you're too young to be on progesterone or you are too old to start hormone therapy, not myself personally, but just in things that women have been told regarding hormone. Can you clarify who hormone So, when you enter your mid to late thirties, you stop ovulating as frequently.

Myths about estrogen, cancer, and the WHI 17:28

And so that's when, and you may start to experience things like insomnia or mood issues or anxiety or crazy periods. and what that should tip your doctor off to, especially if these things are new, is maybe your progesterone is low. Is that something that you actually need to test for? There's two really polarized camps about testing and we can get into that if we want to. But I don't think pro-gesteron is one of those things that have to be tested. If you have those symptoms progesterone has so few downsides that to me, it makes sense to try it and see if it helps, especially with sleep because we know that that lack of sleep just contributes to.

you know, weight gain, depression, it just crashes everything else in your life when you're not able to sleep. So that is a good first step. You'll hear people saying, oh no, you've got to be on estrogen and progesterone. No, You don't. you can be progesterone alone until it stops working. And when does it stop working? When your estrogen levels get low enough that you need to have that added in order for progesterone to be able to do its job most effectively. So I, for instance, took progesterone.

I took 400 milligrams for years and years, and then it stopped working. And then I didn't have anything because I was like, well, you know, I don't know about the whole estrogen thing. several more than several years ago. And then I went back on progesterone, got some estrogen patches, and suddenly my sleep got so much better. Like, you know, I've got an aura ring that tracks my asleep. I think I was getting maybe 10 or 15 minutes of deep sleep a night. It was just awful and then I went on the estrogen with the progesterone again and now I routinely get over an hour of the deep deep sleep and I get great REM sleep, and you know, sort of like the lights turned on again.

So, younger women can benefit from progesterone alone as you move into your forties, and you start to approach the average age of menopause, which is 51, you may need some estrogen and. This is where I feel like. Personally, I feel like testing can be beneficial because you want to kind of see where somebody's ratios lie. So what is your ratio of estrogen to progesterone and how far do we have to go? Yes, your hormone levels do vary throughout the month or the day, but guess what? So does blood sugar and we use that to make clinical decisions all the time.

That argument holds no weight with me whatsoever because our our lab tests are always a snapshot in time, except for maybe hemoglobin A1c, which is a little bit broader time period. So at that point, you may wanna add estrogen. And then once you get into menopause, we want to preserve bone, brain, and heart health, because those are the three areas where loss of estrogen really starts to affect the health of those body systems. So, I like my clients to have an estrogen level of at least 60, and hopefully around 100, because once you get around to 100 hot flashes are pretty much gone at that point bone health is protected at a level 60 and above.

And then with, you know, brain health, we still don't know that's a whole body of evidence that that still coming out. And there's some really good books about that and the importance of estrogen by Lisa Musconi. So she's great author for your listeners to look into about the role of Estrogen in the female brain. So, yeah. And then after menopause, I mean, the guidelines now say that you can stay on estrogen as long as you want to. It used to be that there was a five-year recommendation, and then you had to stop.

There's still some doctors that are talking about that. That's no longer true if you look at the North American Menopausal Society recommendations. Then there's the question of, Well, is it too late for me to start on estrogen? So the guidelines currently say that you should start hormone therapy within 10 years of menopause or before the age of 60. Well I wasn't menoppausal till I was 59, so I would have missed that boat completely. So, you know, I didn't really fall into that window. And now there's even more people that are saying, well, it's not too late, that it is never too light.

And that is open for debate from a cardiovascular standpoint, because when you get into your 60s and older, you are more likely to have plaque laid down in your arteries. So what happens is when start estrogen, your artery becomes more elastic. And that can cause plaques to rupture and potentially cause a heart attack or a stroke. So, depending on how conservative you are, I have a colleague, Lindsay Berkson, who is very, very pro estrogen and your listeners may want to look her up. and she recommends doing an LP little a, which is a cholesterol test that is marker for cardiovascular disease, a carotid Doppler, and a coronary calcium scan.

Because a Coronary Calcium Scan will look for plaque that has already hardened in your coronal arteries. It won't catch anything that's not hard, but it is one way to look at what your pre-existing cardiovascular risks are. For instance, I have a client that had a coronary calcium score of 300 and something, and she's on hormones, but she was on them before she hit the age of 60. I just had one done in the last year, it was zero, my cholesterol is sky high. Advanced lipid testing tells me and my doctor that my cholesterol being high is really not an issue because I have fluffy particles.

I had a coronary calcium scan of zero. So we are not worrying about that right now because i'm not taking a step. We would have to go another route on that. You know, it's really interesting. I think there's like a bit of controversy about hormone replacement therapy, especially coming from the natural world too, because it is like, oh, these are medications or these are hormones do we need them and you know when you're 75 should you have the same hormone levels of a 25 year old woman and I just find it very fascinating because I recently learned that humans are the only animals that go through menopause, except for whales.

Apparently, whales do go to menipause. And essentially, most animals, they have their fertility, like it does decline with age, but like shortly after their virtuality ends, so does their life. Whereas women, you know, we can live for many, many years. 10, 20, 30, 40, 50, 60 years after the end of our fertility, right?

Who can benefit from hormone therapy 25:48

When we get into that menopause state. What are your thoughts on, I guess, levels of hormones? Should we aim for 25-year-old hormone levels when we're in perimenopausal menopsis? should we still aim to be menstruating? I know there's different schools of thought on that. uh personally i do not want to have a period for the rest of my life so there is something called the wiley protocol which does aim to keep you in your you know mid-20s hormone levels throughout your lifetime and i'm like oh no no That's a no for me.

I don't support doing that. What I do support is making sure that your levels are high enough that you're getting, I mean, if you are going to do it, you should just do in a way that's going give you the protection and the relief of symptoms that are looking for. So my doctor was like, Well, I just start people on the lowest patch and give them 100 milligrams of progesterone and send them on their way. And I'm like, that's great. She's like I know you're much more nuanced about what you want for yourself.

I am because I have osteopenia. You know, I've been lifting weights since I was 50, eat well, do all the things. And I don't want this to progress to osteoporosis. So I have been able to finally get my level up over 60. I had breast tenderness that was just driving me crazy, and I'm never going to get there, but I finally did. But symptom relief is super important. And then prevention of chronic disease is also, to me, as important because I want to be able to get out of a chair and go get in on an airplane when I'm 80.

I read something recently as I've been moving more into longevity work that said a woman's average lifespan is 81, but only 63 of those years. are actually a good health span. And I'm like, well, why do we want to have 20 years where we are not our most vibrant selves? So, you know, if women want stay on hormones, I think that's fine. I personally plan to do that unless there's a reason not to. When you started asking this question about, I can't remember how you started it, but I see women all the time that say, you know, a gave in and went on hormones.

And I'm like, how is that a giving in or a shamey thing? I mean, You're replacing what you've naturally lost. It's like telling a diabetic, well, why are you replacing your insulin? Well, first of all, because you're going to die if you don't. But I just don't understand that mindset. And so part of what I try to teach women to do is advocate for themselves, to develop a mindset of good self-care, which may or may not, depending on somebody's individual preference, include a hormone replacement.

I know for myself, I did feel like it was too early for me to need progesterone and I was very resistant to it at first. And a lot of the symptoms I had was having new onset irritability, new-onset insomnia. I'm the person that I would I would go out with my girlfriends to a bar during the day without drinking and I'd be able to take a nap at a crowded sports bar. I never had any sleep issues. If anything, like in my early Hashimoto's journey, I wouldn't be sleeping like 12 hours. And all of a sudden I'm having insomnia I was like, who is this person?

This is not me. i'm waking up in the middle of the night. Hashimoto's made me kind of anxious. But once I got that under control, everybody's like, wow, you're like the calmest, most serene person. And all of a sudden, I was anxious, or I had, those menstrual periods that were coming really, really frequently. I'm talking to women around my age, And I was taking like GABA at the time and I had another friend who was having very similar symptoms and she was drinking a lot of wine. And then I have another friends who is having similar symptom and then she's taking CBD.

Then I another who's like taking, you know, anxiety meds. We're all around the same age. What is the common denominator there? And it was like Oh, progesterone, because that keeps you calm. And holy cow, if you take it orally, it converts into this amazing chemical that keep you like calm and helps you sleep and help to regulate your cycles and makes you still love your husband even though he breathes, right? I began to accept that I was like, okay, this is actually making a difference for myself.

And it's like I feel like my normal self with it. With progesterone and a lot of women will say that it s like oh my gosh, I just I'm not the person that i was before. What are some of the symptoms that you might see respond really well to like progesterone, estrogen, or testosterone therapy because I think for all of us, we were all like, what's wrong with us? Is it like our kids or why are we so anxious? is it because we work? Like, why aren't we having such a hard time? And we we're like going in our heads about what was happening, looking on the outside where it was like a hormonal issue, right?

Yeah, so the things that I've seen respond best to progesterone are anxiety, mood swings, insomnia and fatigue. So those are the top ones. It can help with weight gain, but you know, I find that weight game. There's so much interconnectedness between thyroid and insulin resistance and hormone balance that to say that, yes, progesterone is going to help you lose weight is. probably not a reasonable expectation for a client. Yes, it may help some, but it is definitely not as impactful as some people would have you believe.

And then it helps the crime scene periods too, because you have the progesterone to oppose that estrogen that has been allowed to basically run your body for the entire month when your progesterone goes away. Then when you get into late perimenopause or early menopausal, the inability to sleep really flips more into an estrogen, a low estrogen related kind of thing, which is not to say progesterone doesn't help, but Estrogen becomes one of the big drivers for sleep at that point also also helpful for moods very helpful, for vaginal dryness and skin health.

So I tell people estrogen to me is like. The desert syndrome, everything dries up. So your skin drives up your eyes dry up, your vaginal area drives, up you get recurrent and so estrogen can be super helpful for that. Some people use vaginal estrogen alone, some use both together, and so that's really helpful. And then testosterone, you know, we think about testosterone as really helping with libido. I didn't find that to be true, I just found that I needed to get divorced. That's what was helpful for my libido.

Progesterone, estrogen, and testosterone effects 34:28

But maintenance of muscle mass, it also helps a lot with bone health as does estrogen. It gives you drive. it gives that get up and go and the ability to like start and complete projects and just Feeling an overall sense of well-being and I think that and it can also help with weight as well so I Think testosterone just gets dismissed out of hand as something that what that women don't need and i'm like why It's the on a percentage basis the the highest circulating hormone in their bodies before menopause and then you know our our adrenals do still make testosterone after we go through our ovarian retirement period, as I call it.

But I think it's crazy that we just don't think about testosterone and that the North American Menopause Society only recommends it for low libido. And I don t find that it s super helpful for that. Some people do. But yeah, maintenance of muscle mass to me is super important because if you're not doing that, then your ability to live a vibrant lifespan or health span is going to be compromised. So they all have a role in the progression of a woman's reproductive years. So it's really fascinating because it seems like if you're I would say if your been on progesterone and then your sleep issues come back that could be a signal that your estrogen levels might need some more support and maybe getting those measured.

I have noticed you know a lot of women their skin just starts glowing when they get on estrogen replacement and that's always been Something that I think a lot of companies have noticed that they actually might put estrogen in some of the creams, right? And definitely the vaginal dryness and recurrent UTIs. This is something that is really, really relevant for a lots of women and can cause a lotta suffering. I mean, it's like who wants to have a UTA every other day? So this is the important consideration.

Think about women in nursing homes who get septic from recurrent UTIs. It's like, should we just do vaginal estrogen as a matter of course, you know, for anybody who has an issue with recurrant UTS? I mean, there's no reason for that to happen when it's so effective. Yeah, absolutely. And I know we had, I went through some geriatrics training and it was essentially if an elderly person in a nursing home presents with mental status changes that it oftentimes a UTI is going to be the first thing that you would want to look for.

So it can be a very, very serious consequences of that. I had a relative who, this was a gentleman, but he ended up actually the family thought he was you know on his deathbed and it was it, was a UTI and that that can be treated of course but if we can prevent it that's even better. The highest circulating hormone before menopause. It's interesting because we oftentimes, when we talk about female hormones, we talked about estrogen and progesterone, and testosterone has this sort of, I guess, reputation for being a male hormone, but women have a lot of it as well.

Now, We had talked a little bit about like the availability of It because generally speaking, women do not need like men doses. testosterone, right? Um and I've also seen some people who are very afraid of utilizing it because they have been overdosed and they can get like, you know, a lot of uh male changes that they're not that that are not going for. So, they might have some extra facial hair. They might hair loss and some of that um some of that situation that they're really not hoping for, maybe some aggression.

Can we talk through that? I know there's some clinicians that also use pellets. Yeah. Pellets are tricky, not a fan, especially if you're starting testosterone therapy. So pellet are about the size of a grain of rice. They're impregnated with testosterone and sometimes estrogen is added in there too for convenience. And then basically a surgical incision is made at the top of your butt and insert the pellet and do a stitch and send you on your way and it lasts three to four months. which all sounds very convenient until you get the wrong dose and then you're stuck because that pellet is not coming out.

And so if you got overdosed on testosterone, which is very easy to do in women, You know, there's nothing that can be done until that pellet cycle runs its course. The other thing is that at the beginning of a pellets cycle, you tend to get a big release of testosterone, then it plateaus some, and then at end, your testosterone levels come down and you don't feel nearly as well as you did. You know, I tell women, get started, figure out what your dose is. If you then want to go on a pellet, fine, but it's very expensive.

It's a surgical incision, so there's risk of infection. And I just, depending on your activity level, let's say you have a pellet and you decide you want to start working out harder, your body is going to use more of the testosterone in that pellete. So it's not going last as long. There's all kinds of uncontrollable things that can go on with that. With the Dutch hormone test, you can actually see the metabolic pathways that a woman's body prefers for metabolism of testosterone. So if you see that she is more prone to favor the pathway that results in the side effects that you talked about, so chin hair, loss of head hair aggression, those are the big ones.

Acne, that's another one. There are some others that are a little less common unless you're way overdosed. But if you can see that that pathway is preferred, you could actually do things to block it that can prevent those side effects from happening. So I like the Dutch test. I use it. The metabolism of the various hormones, I think, is important to see because we want to be able to manipulate the non-optimal pathways to make sure that someone is getting the benefit of their hormone therapy or not increasing their risk in some way of developing cancer.

Say, if their body prefers the 4-hydroxy pathway for estrogen, we can do things to fix that too. I don't know if I answered your question. My brain just kind of went boop. No, you absolutely did. I think the underlying concern is that women generally needs lower doses than men do. And then we also, we don't really have like a woman's testosterone prescription option. So you have to get it like compounded or you to use the men's doses in smaller levels. The pellet business is like quite a money-making machine for a lot of clinics.

practitioners who are very well-intentioned that want to start off with offering hormone replacement therapy, that might be something that is a little bit easier for them. But it might not be the best for a patient because, like you said, if you don't know what your optimal dose is and all of a sudden you're overdosed, you are going to be overdosing not just for one day. It's going to take months for you to get that worked out of your system. I love that you use the Dutch test to help understand the different hormone pathways because that's when you can get yourself in trouble with the even bioidentical hormones.

If they go down the wrong metabolic pathway and they turn into the less beneficial versions, and I know for myself personally, I had DHEA that I was utilizing and it went down the wrong pathway and so I ended up getting like the chin hairs.

Testosterone dosing, pellets, and Dutch testing 43:48

Inquiring minds want to know what do you recommend for that? To prevent that? Yeah, to move some of those pathways to the more beneficial pathways. With estrogen, it depends on where the issue is. So in phase one in the liver, if somebody's not metabolizing their hormones effectively, I will often use DIM. to push the pathway into the safer 2-hydroxy pathway. If somebody has low estrogen, I will not use DIMM because it's going to lower their estrogen overall a little bit more. You'll hear people say that doesn't happen and I've seen it happen too often to believe any of that.

So in that case, um i will use uh quercetin i'll use rosemary extract um what's the other one i like i can't remember off the top of my head but there are there different options And then a phase two is an issue where methylation is not good. There are a lot of options to help that. So magnesium, trimethylglycine, B vitamins, calcium deglucarate is one that I use quite a bit. With estrogen, make sure that you open up the pathways in reverse. So there's phase one, two, and three. Three is pooping estrogen metabolites out in your bowel movement, so you don't want somebody to be constipated.

You have to fix that first, then back up and fix phase two and then fix one. Because otherwise, you're just basically filling up a bathtub with these metabolite. I use DEM sometimes to block the conversion of testosterone to estrogen because that can happen. So that could raise a woman's estrogen level as well. And then to block conversion to the chin hair producing metabolites. I like stinging nettle and pagium and there's actually a triple combo that is in one product. I like that because it blocks DHT, which causes hair loss and all that kind of stuff.

There's a whole toolbox of things that are available without prescriptions, but you want to work with somebody who knows what they're doing before you start just pulling things off the shelf at Whole Foods because you can get yourself into some trouble doing that, especially with the DIM. Yeah, that makes so much sense because one, you wanna figure out what your pathways are turned towards. you want to figure out what levels are going to be optimal for you. So you need to do the blood work and then you needed to hear out how to adjust those pathways.

And I feel like this is where functional medicine is really critical because we can have hormone replacement therapy. But if you were to go to a traditional doctor that maybe just got their start with it, they would be like, here's some pellets or here some this and you might not have very good results with. You might in fact have side effects. You might have complications, but when you combine that with the whole functional approach, you can actually optimize the pathway. So yes, your getting more testosterone or you're getting estrogen, it's actually going to where it is supposed to be going versus you support this bad pathway and you are just kind of putting more fuel on the fire.

I love that you do that for your clients and it so important. And I will say, I applaud you for learning the Dutch test. I've been learning for 10 years and I still feel like I'm learning new things. It's a very, very complicated test that I don't wish upon any patient to do on their own unless they're working with a practitioner. That's another thing. This is going to be one of my soapbox moments, but I how anybody in the world can go on a website and order a test on their own that is as complex as that it is and then they'll show up and go, can you help me interpret this?

I'm like, What the hell did you, if you didn't know what you were doing, why did just spend $425 to order a test that you did not know anything about the interpretation of? And it's that way with gut tests, it is all the things. So I'm glad that people have access to learn about their health care, but man, there are some things that just should not be. I mean, can you imagine a lay person trying to interpret an organic acid test? I'm fully with you. So I am a big supporter of people ordering their own labs, and I'll add some links for that and just really being empowered to have that information.

Some labs that are super easy to understand, for example, food sensitivity tests, like if it's red, or if it's elevated, then you're sensitive to it. If it is not, you are not sensitive. That's fairly straightforward. A lot of the thyroid lab tests, if you have a guide, like a one-page handout, and you can kind of understand if your in the optimal range and can understand your lab test. But man, the Dutch test and the organic acid test, I've been studying those tests for 10 plus years and I would say I'm better at organic test than the dutch test I'm still learning new things every day.

I am very supportive of people ordering their own labs, but if you do those two tests, can you make sure you have somebody that interprets them and not somebody who just started working with those tests because they're so nuanced? And then I think the other thing is when we're talking about the metabolic pathways, We can't rule out the importance of gut health, because a lot of times a phase two issue is related to poor gut, health with with beta glucuronidase. So, cause that. unpackages the estrogen that's ready to be eliminated and allows it to recirculate.

I don't know, there's so much to it. It's really hard to tease out one thing and say, oh, it's definitely this when there could be more aspects going on. Throw in thyroid health because that affects your hormones as well. Yeah, absolutely. I definitely think gut health and a lot of times increasing your fiber intake is something that women oftentimes have to do in perimenopause, menopaus, just to prevent some of those estrogens from recirculating. And so I feel like, you know, it's not just getting on hormone replacement that you might need to, do is you want to work through some these other pathways that for whatever reason might be impacted.

I am curious, what do you typically see as the gut health culprits that can sabotage the estrogen pathways? Do you see specific bugs or infections? I can't remember specifically which bugs produce the beta-glucuronidase, but that's actually an overall marker of gut-health. I mean, there's the histamine producers that that the Dutch test part, but if people are having histamine issues, things like Klebsiella and what are the

Gut health, histamine, and hormone metabolism 51:38

other big histamines? Morganella. So those are some big ones that are histamin producers that can have a big impact on your experience of perimenopause because a lot of women have histomene issues when they enter periminopausal. Okay, so I'm gonna ask you a different question. I want to ask the histamines. So we talked about beta-glucuronidase, which you could find elevations of that on a test like the GI map test. And there's various types of gut bucks that can elevate it, potentially mold exposure can cause an elevation in that.

But there is also this interesting connection between histamine and hormone imbalances and perimenopause and menopausal and also our gut bugs. Can you speak to that a little bit? Yeah, so when your estrogen levels are swinging around wildly in perimenopause and generally way out of balance with progesterone, you can start having issues with histamines. So histamine are found in foods. We typically think of a histamin reaction as oh, you're having hives or you are sneezing or whatever. And those are symptoms of histamine reactions, but it can also be fatigue.

That's a huge one. Reactions to foods that you never had a reaction to, especially things that are fermented. So fermented foods contain a lot of The other thing we have to think about is various gut bugs that produce histamine, like Klebsiella or Morganella. Those are some, not to get too technical, gram-negative bugs or opportunistic bugs, that live in our gut. the gut environment is not optimal, which means that the bugs that are supposed to be there aren't there in sufficient quantities. These opportunistic bugs overgrow, and then they start to release these compounds that can cause, I think citrib actor is another one, that cause histamine reactions.

There are various ways to deal with histamines. One is to eliminate histamin containing foods, but that's a really long list. So part of it is just figuring out what you are sensitive to. You can also use a DAO enzyme supplement, which I probably should have talked about too. DAOs is an enzyme that breaks down histamine and we become deficient in it in some cases, but that can be supplemented. And then there are the antihistamines, obviously, that it can used as well. But gut health is a huge part of histamine and making sure that your estrogen and progesterone levels are balanced as well as you can get them to be.

Yeah, it's been really interesting because that's such a relevant topic, women going into like perimenopause, menopausal, where all of a sudden histamine is an issue. And so it is something that is another consideration as your optimizing your hormones. I'd love to ask you if you have some signs that a woman might be a good candidate for hormone therapy, Yeah, I can talk about who is and who isn't and what the considerations are. Given the data that we have access to now that keeps coming out and getting updated, most women actually are pretty good candidates for hormone replacement therapy.

The people that you definitely need to have a broader conversation with about risks and benefits would be women that are homozygous for various clotting factors who have had a blood clot. Especially if it is unprovoked. So a provoked blood clot means that you had something happen to you like an injury or whatever that caused your blood clot and you can specifically identify what that cause was. It gets treated with anticoagulants for a specific period of time and then you kind of go on your way.

The un-provoke ones are ones that just show up and These are generally, I'm going to say generally and it might not be generally but A result of a genetic issue. So there are genetic things like factor five Lydon, which is fairly common that can cause you to have an increased risk for blood clots. Um, so people that have that it's not an absolute country indication. I mean, if I had a client who was homozygous, not heterozygos, I would probably. maybe think twice and have a conversation about risks and benefits, but the transdermal estrogen products seem to not increase clotting risk.

So they may be a candidate depending on what their experience of perimenopause and menopausal is. I mean, if you're having 100 hot flashes a day and your quality of life is miserable, then you know, it may be worth taking that risk. Heterozygous, not as much of a risk, people that have had breast cancer, there's more and more data coming out about this. There are 26 studies that had been done that look at breast-cancer recurrence when hormone replacement is given to women that've had an episode of breast and 25 of those 26 studies show no risk of recurrence and no increase in overall mortality.

There was one study called the Habit Study that did show an increased risk, but it had some flaws. Basically, the hormone regimens they looked at weren't comparable. Some women were on tamoxifen and some weren''t for various lengths of time, so it was not a really clean study. I would say the majority of oncologists and other physicians would still not be excited about giving women who have had breast cancer or another hormone

Candidates, risks, and shared decision-making 58:28

sensitive cancer. Hormone replacement therapy, but I think we have to really start to look at that data and there are physicians right now who are making it, you know, their life's purpose to spread that news. What is her name? Corinne? Cren, man, I think on, she's on Instagram, She's a physician. She had breast cancer in her twenties and she is very, very knowledgeable about what the data says about giving hormones after breast. Cancer. So I, think that's an exciting thing for women who have had cancer, who are really, really having a tough time and are not.

getting relief from, say, something like Veoza, which is a fairly new pharmaceutical that's indicated for hot flashes, but it's not indicated from all the other things that go along with menopause. So I think again, we're back to quality of life and shared decision making. That's super important. And really looking at the data that is out there and then making the decision that you feel like is right for you. Yeah, I think a lot of things to consider and I know some women might be feeling overwhelmed and unsure about hormone therapy.

Do you have any advice to help them make an empowered choice? Yes, without having to have a medical degree, inform yourself about the data and what it actually says. I can't recommend estrogen matters enough. Find some people out there in the medical community who are really talking about hormone replacement therapy, like Mary Claire Haver. You can't pull up Instagram without seeing 18 posts from her and she's very knowledgeable. Kelly Casperson is another one. And listen to what those people have to say and then consider what is your experience?

What do you want for yourself? You know, I thought long and hard about starting estrogen, even though I know what the data says, because I was like, well, am I just gonna, you know do something stupid here? And I like no, no I have to be able to sleep. So, learn enough to know your preferences are. And then the other thing I tell women is if you start, your not marrying hormone therapy. I mean, if your start you can always stop. and just understand that it may take some dosing tweaks to get you to where you need to be.

And that's very, very normal. But I would say, you know, try it for six months, do it as an experiment. Some people don't feel better on it and you can always stop. There are plenty of options out there in dosage forms that you could try. and you may land on one that works better for you than another does. Some people don't like patches, they fall off or whatever. I love them because they're convenient. But some people do better with gels or sprays or, whatever, but I would say, use a topical estrogen if you're gonna go that route.

It's really helpful and sage advice. I'm so grateful for all of the work that you've done on this researching it and spreading all the awareness. i would love to get a little bit of information from you where women can connect with you and where they can pick up your book. Can you tell us a So my website is drannagarrett.com spelled with two R's and two T's. I am Dr. Anna Garrett on all of the social media sites. So I'm on Facebook, Instagram, TikTok, believe it or not, LinkedIn. And I also have a private Facebook group called the Hormone Harmony Club.

close to 13,000 women in there now and we are talking about all things hormones. And then my book is available on Amazon and it also has its own website. So www.perrymenopausebook.com. I wrote it in 2019, but there's nothing in here that's not applicable today. I've gotten really good feedback on it.

Where to find Dr. Garrett and rapid-fire questions 1:03:38

People find it very accessible and not written at such a high level that it's a slog to get through. Thank you so much for creating these resources. We're going to go ahead and put them in the show notes so people can access that. I thought this was really great and super informative. Really, really loved our interview. Our audience is going love it. Before I let you go, can we do a quick rapid fire questions? Sure. Myth or fact? Women don't need testosterone postmenopause. myth. And why is that?

Because they have testosterone circulating throughout their bodies at all points in their lives and it helps them feel so much better and have a better quality of life and overall feeling of well-being. Thank you so much. That's wonderful. What's one wellness hack that you would not participate in? I know a lot of my ladies with thyroid issues said cold plunges but there's other ones out there. Cold plunging is one. Weighted vests I have questions about. I don't know that the data actually supports at this point using a weighted vest to do your walks.

If you had a supplement police come to your house and say, I'm going to confiscate all of your supplements, but I am going be a nice guy and leave you just one, which one would you keep? Magnesium. because it was life-changing for my sleep and it's used in so many cellular processes that there's no way anybody's prying that out of my hand. I love that. Dr. Anna Garrett, thank you so much for joining us on the Thyroid Pharmacists Healing Conversations Podcast. This has been incredibly insightful.

Loved my time with you. Thank you for all the work that you do for women around the world. And everybody listening, Thank You so Much for dialing in. I hope this conversation has be helpful on your healing journey. Until next time.